Provider Demographics
NPI:1083673545
Name:GILMER, SHANNON KATHRYN (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:KATHRYN
Last Name:GILMER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KATHRYN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:116 S SEASHORE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-5707
Mailing Address - Country:US
Mailing Address - Phone:228-365-1124
Mailing Address - Fax:
Practice Address - Street 1:4013 BEATLINE RD STE A
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-4135
Practice Address - Country:US
Practice Address - Phone:228-200-0720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903276363LP0808X
VA0001186397163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health